Pressure for Organs Opens Pandora’s Box
Even more pressure to increase the use of NHBD is apparently coming, even though the public has been kept largely in the dark about this new method of obtaining organs. For example, last November, an advisory committee to the US Department of Health and Human Services recommended that, in the future, all hospitals should establish policies and procedures to “manage and maximize” NHBD and also be required to “notify organ procurement organizations prior to the withdrawal of life support to a patient, so as to determine that patient’s potential for organ donation”5 (emphasis added).
Unknown to most of the public, hospitals are now already required to report every death to the local transplant organization even when tissue or organ donation is refused. If enacted, this new proposal could put further pressure on distraught families.
Ironically, at the same time, new information is coming forward about these so-called “hopeless” patients who are considered potential NHBD candidates. A September 2003 article in The New York Times featured Dr. Joseph T. Giacino and others who work with people who have had severe brain damage but who are now showing signs of “complex mental activity” – even after months or years with little sign of consciousness.6 And, of course, there are many reported cases, even in the media, of brain-injured people who improve or even recover long after doctors declared them hopeless…
Linking the so-called “right to die” with organ donation – as NHBD does – has truly opened Pandora’s box. While organ donation can be a gift of life and a worthy goal, we must not allow the deaths of some people to be manipulated to obtain organs for others.
References: 2) “The Death Watch: Certifying Death Using Cardiac Criteria” by M.A. DeVita, MD, Univ of Pittsburgh Med Ctr. Prog Transplant 11(1):58-66, 2001.
5) US Department of Health and Human Services Advisory Committee on Organ Transplantation, Recommendations to the Secretary, Nov 2002. Available online at: http://www.organdonor.gov/acotrecsbrief.html.
6) “What if There is Something Going On in There?” by Carl Zimmer. The New York Times, 9/28/03 [excerpts from “Update on Non-Heart-Beating Organ Donation”, Voices, 12/03-1/04, by N. G. Valko, R.N.]
NHBD
Comments from N Valko, RN: A few months ago, UNOS (United Network for Organ Sharing, the big national transplant group) contacted me for permission to reprint one of my articles criticizing NHBD for their medical resource book for medical personnel and clergy. I was pleasantly surprised by this
and, of course, I gave my permission. Obviously, ethical concerns about this procedure are not just hysteria.
One of the problems with the current discussion of NHBD is the focus on how short or long the interval should be between heart arrest and harvesting.
While this is a problem in itself, this controversy avoids the real ethical problem: death is being caused or hastened by the sudden withdrawal of a ventilator (no weaning process) to get organs as fresh as possible.
Without the withdrawal of treatments promoted by "right to die" groups, most NHBDs (the controlled kind, not the ones from failed resuscitation attempts) would not be possible since waiting until natural death would result in potentially damaged organs. This kind of NHBD relies on a hopeless diagnosis-usually either eventual death or severe brain damage.
Unfortunately, every case I've seen has involved a very quick "hopeless" diagnosis and this can deprive the patient of a real chance at recovery.
For example, brain swelling is common in head injuries and it can take awhile to decrease and thus allow the person to breathe on his own. (Think Jason Childress, the young man whose family fought over removing his vent. When a court ordered the vent removed several weeks after his injury, Jason didn't die as expected by the doctors and he eventually started rehab.)
And the problem of NHBD "failures" where the person doesn't stop breathing within an hour is a real red flag showing that not only are doctors often wrong about their predictions but also that death is being enforced because no potentially beneficial treatment is resumed.
Of course, there are other problems with NHBD such as "irreversibility."
Actually, the traditional standard of death-heart and brain stoppage-had to be changed to IRREVERSIBLE stoppage when CPR was developed because people could now be revived after their heart and/or breathing stopped.
But now in NHBD, irreversibility has been redefined to mean a decision not to resuscitate rather than the potential of resuscitation with CPR. (Of course, DNR decisions can be ethical in many situations but using a DNR to justify NHBD organ harvesting is problematic at best.)
It is ironic that brain death has been touted as the 'gold standard' of death in organ harvesting while NHBD does not require brain death at all.
Even Dr. DeVita, a big proponent of NHBD has admitted in his article "The Death Watch: Certifying Death Using Cardia Criteria" : "While the likelihood of (brain function) recovery decreases with an increase in time, THE POSSIBILITY OF RECOVERY EXISTS FOR AT LEAST 15 MINUTES. If the only concern about diagnosing death were the irreversible loss of brain function following cardiac arrest, than a MINIMUM of 15 minutes o(f) absent and unsupported circulation would be needed to ensure that an individual would inevitably suffer a neurologic injury consistent with the CURRENT CRITERIA FOR BRAIN DEATH." (emphasis added, and a longer period of time than any protocol I have seen since it reduces the chances of a useful organ.)
However, Devita defends his 2 minute death watch as 'sufficient' because it "is consistent with current medical practice" and that "the 2-minute time span probably fits with the LAYPERSON'S conception of how death ought to be determined." (emphasis added.)
Ironically, when I was a hospice nurse, we were told to always take our time before declaring death since sometimes the patient could resume breathing or heartbeat for a short time even after several minutes of no perceptible heartbeat or breathing.
Moreover, there is a fascinating article on studies with animals where circulatory arrest was induced and lasted up to 10 minutes. Note that the authors talk about brain damage, not brain death:
http://riker.ps.missouri.edu/deptpubs/surgery/traumaresuscitation/trnl95/traumaresuscitation5.html
Reversal of Incipient Brain Death from Head Injury Apnea at the Accident Scene. Animal studies have demonstrated that head injury associated with loss of consciousness is always associated with apnea.
Prolonged apnea may be the mechanism of death in head injury at the scene of the accident. The authors personally documented two cases of prolonged apnea at the scene of injury in patients who initially appeared to have no brain function. The first author discovered a woman pinned under an overturned car within 15 minutes of the accident.
Examination disclosed no carotid pulse, no respiration, no response to deep pain and no corneal reflexes; the pupils were fixed and dilated. After 12 minutes of apnea, artificial ventilation was performed and the patient recovered completely.
In a second case, a 2-year-old child was struck by a car. The second author was present at the scene of the accident and examined the child. There was no radial pulse. Apnea, flaccidity and cyanosis were present. CPR was started, after 8 minutes the child gasped and gradually resumed breathing and had an uneventful recovery. N Engl J Med 301:109, 1979.
Dr. Joseph Redding has demonstrated that apnea is followed by circulatory arrest within 6 to 8 minutes. JAMA 182: 163, 1962.
Resuscitation before circulatory arrest occurs is associated with little brain damage.
Two minutes after circulatory arrest has occurred resuscitation with IPPB/CCCM and epinephrine resulted in 100% survival with no brain damage.
Resuscitation 5 minutes after circulatory arrest resulted in gross brain damage in 50% of the animals.
Resuscitation 10 minutes after circulatory arrest, total apnea time of 15 minutes, resulted in brain damage in all of the animals.
Thus, in airway obstruction and/or apnea, the Golden Hour of Resuscitation is reduced to 5 to 10 minutes after injury if brain damage is to be avoided.
Dr. Kenneth Mattox referred to this as the Platinum Five Minutes in his lecture, "Another Myth Where is the Golden Hour?" given in Kansas City in December 1994 at the Advances in Trauma Symposium of the Region VII American College of Surgeons Committee on Trauma.
The public has been told that brain death excludes any possibility of awareness or survival.
Can the same be said of NHBD? Obviously not.
Do organ donor cards even mention the possibility of NHBD? No, yet states are passing legislation mandating that organ donor cards be followed even over family objections. Informed consent? No way! Nancy V.
http://www.wesleyjsmith.com/blog/labels/Organ%20Donation.%20%20Non%20Heart%20Beating%20Cadaver%20Donor%20Protocols.%20%20Heart%20Death..html
Friday, March 23, 2007
Wesley Smith
Organ Hysteria
I think that the hue and cry against non heart beating cadaver donor protocols–what I have called "heart death"– is misguided. And it reflects a misconception about the concept of "brain death," a popular term for death by neurological criteria–which does not mean that every brain cell is dead, but that the brain and each constituent part has ceased to function as a brain. What is even more ironic, is that some pro life advocates oppose brain death as not really being dead because the patient's heart is still beating.
This statement from a story on this issue in LifeSite is wrong factually:
"The person is not dead yet," said Jerry A. Menikoff, an associate professor of law, ethics and medicine at the University of Kansas. "They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death."
No, irreversible cardio/pulmonary arrest is dead, and in these cases the arrest is irreversible because there will be no CPR. When writing Culture of Death, I inquired of many neurologists as to whether patients would have any awareness after such a time. The answer from pro life and non pro life doctors alike was unanimous: No.
Death by neurological criteria, is the other method of declaring death. In other words, there are two methods of declaring death, with heart death being the tried and true one from time immemorial.
Some of these "heart death" protocols permit organ procurement as short as 2 minutes after cardiac arrest. I think this is too short, not based on the patient having any awareness–which I was again told unanimously was not possible–but based on giving the benefit of the doubt to caution and the lack of tests about whether such reverses are irreversible after such a short time.
I think a few people believe there should be no organ transplants because they don't think it can be done ethically. They don't believe in brain death–which is an arguable position. But they also don't believe in heart death along these protocols. That's fine. But we should not let these well meaning advocates panic us.
The real danger, in my view, to ethical organ procurement comes not from heart death donor protocols, or from brain death procurements, but rather from shoddy following of ethical rules and from advocacy among many bioethicists to expand the donor pool to people who are not really dead.
Let's keep our priorities straight.
Labels: Organ Donation. Non Heart Beating Cadaver Donor Protocols. Heart Death.
posted by Wesley J. Smith
10 Comments:
Lydia McGrew said…
I think you may be right here and don't have a strong position either way on NHBD. But I'm a little hesitant about the claim that the cardiac arrest is irreversible because there will be no CPR. I mean, isn't "irreversible" supposed to mean that it _can't_ be restarted, not just that in fact it _won't_ be restarted? Saying it's irreversible because in point of fact we aren't going to do CPR sounds a little uncomfortably like saying that someone is terminally ill because we've decided we are going to stop giving him food and water.
Please understand that I don't mean to say that NHBD is like dehydrating the person to death. I'm just making the analogy to show why some people might be uncomfortable with using a term like 'irreversible' as a designation for what we intend or don't intend to do for the patient.
Is it not at all bothersome, though, if this is true, to think that organs are being procured from someone who, let's say, could be "brought back" and even become fully conscious again later and so forth if he were given CPR?
Perhaps there's just something I'm not getting, though.
March 23, 2007
Wesley J. Smith said…
Yes, well with CPR and intensive intervention, people have been revived after 15 minutes. But without it, they will not spontaneously revive. If they have refused such interventions–which they have the right to do–then after 5 minutes it is irreversible.
Either that, or we can bring organ transplant medicine to a complete halt, over matters that are not really of major ethical concern.
March 23, 2007
Lydia McGrew said…
Thanks, that's a helpful clarification. What you're saying then is that it's really objectively true after five minutes with _no_ CPR or intervention that the condition is irreversible. That is, if we sat around and did nothing for five minutes and _then_ started up the CPR and such, it wouldn't work. So the irreversibility really is objectively true of the patient's condition because we've already in the past (the five minutes since heart stoppage) not given CPR. That does make a difference. It's not like the organs are being taken from a person who right then still could have things done for him that could bring him back completely.
March 23, 2007
Wesley J. Smith said…
No. I didn't say that after five minutes CPR and other interventions might not be able to bring someone "back." I don't know that. I am saying that there will not be CPR and so the collapse of cardio/pulmonary functioning at that point is indeed, irreversible.
March 23, 2007
Lydia McGrew said…
Okay. I apologize for over-extrapolating. So here, I think, must be the significance of the 5 minutes: It's that after 5 minutes we can be sure the person won't _spontaneously_ "wake up" if nothing is done, whereas after merely 2 minutes there's a concern that the person might spontaneously come to and hence isn't really physically dead. Is that right?
March 23, 2007
Wesley J. Smith said…
Yes. Of course, there has been no formal testing about this matter–how could there be–but the 5 minutes seems right since by then, any chance of spontaneous revival after 5 minutes without heartbeat or breathing would be as close
to impossible as one can say using that term.
March 23, 2007
T E Fine said…
This is evidence that I read too many of the *wrong* books and websites…
Okay. The reason I'm bringing this up has nothing to do with Near Death Experiences (NDEs), but it does explain what happens to the brain when it gets shut down.
The doctor I'm quoting from is Dr. Pim van Lommel, whose article was published in THE LANCET. The article is about near-death experiences, *BUT* Section Five explains the effect of cardiac arrest on the brain. It's the easiest explanation of heart death and brain death that I've ever read, and *that* is why I'm quoting it here, to explain why I don't think that heart death is bad criteria for organ donation.
Quote from Dr. Pim van Lommel:
We know that patients with cardiac arrest are unconscious within seconds. But how do we know that the electroencephalogram (EEG) is flat in those patients, and how can we study this? Complete cessation of cerebral circulation is found in cardiac arrest due to ventricular fibrillation (VF) during threshold testing at implantation of internal defibrillators. This complete cerebral ischemic model can be used to study the result of anoxia of the brain.
…Through many studies in both human and animal models, cerebral function has been shown to be severely compromised during cardiac arrest, and electrical activity in both cerebral cortex and the deeper structures of the brain has been shown to be absent after a very short period of time. Monitoring of the electrical activity of the cortex (EEG) has shown that ischemia produces a decrease of power in fast activity and in delta activity and an increase of slow delta I activity, sometimes also an increase in amplitude of theta activity, progressively and ultimately declining to isoelectricity. More often initial slowing and attenuation of the EEG waves is the first sign of cerebral ischemia. The first ischemic changes in the EEG are detected an average of 6.5 seconds after circulatory arrest. With prolongation of the cerebral ischemia, progression to isoelectricity occurs within 10 to 20 (mean 15) seconds from the onset of cardiac arrest.18-21
…Anoxia causes loss of function of our cell systems. However, in anoxia of only some minutes duration this loss may be transient; in prolonged anoxia cell death occurs, with permanent functional loss. During an embolic event a small clot obstructs the blood flow in a small vessel of the cortex, resulting in anoxia of that part of the brain, with loss of electrical activity. This results in a functional loss of the cortex like hemiplegia or aphasia. When the clot is dissolved or broken down within several minutes the lost cortical function is restored. This is called a transient ischemic attack (TIA). However, when the clot obstructs the cerebral vessel for minutes to hours, it will result in neuronal cell death, with a permanent loss of function of this part of the brain, with persistent hemiplegia or aphasia, and the diagnosis of cerebrovascular accident (CVA) is made. So transient anoxia results in transient loss of function.
In cardiac arrest global anoxia of the brain occurs within seconds. Timely and adequate CPR reverses this functional loss of the brain, because definitive damage of the brain cells, resulting in cell death, has been prevented. Long lasting anoxia, caused by cessation of blood flow to the brain for more than 5-10 minutes, results in irreversible damage and extensive cell death in the brain. This is called brain death, and most patients will ultimately die.
From these studies we know that in our prospective study1 as well as in the other studies2,3 of patients who have been clinically dead (VF on the ECG), total lack of electric activity of the cortex of the brain (flat EEG) must have been the only possibility, but also the abolition of brain-stem activity, such as the loss of the corneal reflex, fixed and dilated pupils, and the loss of the gag reflex, is a clinical finding in those patients.
…Unquote.
I stop there because the conversation moves on to NDEs and that's not at all relevant, but as you can see from the detailed explanation that Dr. von Lommel gives, in a very short period of time after the heart stops beating, the brain stops functioning altogether. CPR doesn't restore normal blood flow to the brain and cannot make the brain work properly – it's only when CPR leads the brain stem to take over the heartbeat again that the heart – on its own – can generate enough blood flow to get the brain up and running.
THEREFORE, one can conclude (I believe correctly) that when the heart stops beating, the brain is unable to function at all, and therefore brain death officially occurs. The cells don't have to be dead for the brain to stop functioning properly – the brain won't generate anything while deprived of necessary bloodflow. The person isn't inside his or her head anymore.
If anybody's interested in the entire article, you can read it here:
http://iands.org/research/vanLommel/vanLommel4.php
Section Five has all the details about what the brain is *not* doing when the heart is not beating. Even if you're not into NDEs it's a good read – if nothing else you learn a little bit more about what happens when we're in the process of dying, and that takes some of the fear out of the mystery.
March 23, 2007
boinky said…
Most of the cases, no problem.
But they mention that it would allow people with terminal neurological disease to donate organs…meaning of course we'll pull the respirator to stop their heart then take their organs. I have real problems with that one.
March 25, 2007
Wesley J. Smith said…
Boinky: Thanks for stopping by. Yes, in Culture of Death I also expressed concern that this protocol could become a way for very depressed disabled people who require respirators, to give life "meaning" by becoming an organ donor. I think the issue you raise requires real concern and that perhaps such people should not qualify as donors to prevent such a scenario.
March 25, 2007
Lydia McGrew said…
I'm trying to see how such a protocol would work. It seems to me there's a real practical problem, because many people who would require a respirator _would_ become at least for a short time disabled–cognitively or otherwise–during or just before the time that they required a respirator. So if there were a rule against using this for disabled people, it would seem as though that would rule it out for anyone on a respirator.
_I_ don't mind that myself, but is it likely that anyone would accept it? Like Boinky (and apparently like a lot of people who object to this protocol) I think there's something unpleasant about the image of taking somebody off a respirator just so you can take his organs. Yet how else could it ever work for respirator patients?